Approach to the patient with nausea and vomiting

Nausea and vomiting are common symptoms in medicine, usually occurring together but sometimes occurring separately. Nausea is the sensation of impending vomiting. Vomiting is the act of forceful expulsion of gastrointestinal contents through the mouth. Nausea and vomiting may be labeled as acute (<1 week duration) or chronic.

There are numerous etiologies of nausea and vomiting, but the first step in approaching these patients is to categorize them into a general category, guided by pathophysiology. The first and most important general cause is obstruction in the luminal gastrointestinal tract. This needs to be ruled out first because of the high morbidity and mortality associated not only with dehydration from nausea and vomiting but also because of the threat of bowel infarction commonly associated with untreated obstruction. Common causes might include bowel obstruction from adhesions, malignancy, intussusception, volvulus, or foreign body ingestion. Emesis in these patients is typically high-volume when complete obstruction is present and is associated with a colicky pain.

The second most concerning etiology would be an intra-abdominal inflammatory disorder. The differential diagnosis for this category is broad and may include disorders such as appendicitis, pancreatitis, and inflammatory bowel disease. In these patients, persistent pain and nausea tend to be more prominent symptoms, with less intense vomiting. It is important to note, however, that many of these inflammatory disorders may lead to partial or complete bowel obstruction.

A third worrisome etiology, although less common, would be an intracranial cause of nausea and vomiting. These patients tend to have intractable nausea, vomiting, and retching without abdominal pain. Although, one would expect a headache to accompany these causes, this is not always the case. Common etiologies of intracranial nausea and vomiting might include an intracranial or subdural hemorrhage, malignant hypertension, or malignancy.

A fourth etiology that needs to be considered is drug overdose with either a prescribed or illegal drug.

After these four important and often emergent causes of nausea and vomiting have been ruled out, then a plethora of other causes need to be considered. In the case of acute onset nausea and vomiting, viral, bacterial, or toxin-mediated gastroenteritis might be present.

Other potential general etiologies might include gastrointestinal dysmotility such as gastroparesis, metabolic causes such as adrenal insufficiency, drug induced nausea, and vomiting and abdominal migraine.

Also known as:

To be differentiated from regurgitation and rumination.

Regurgitation is effortless reflux of gastrointestinal contents into the mouth.

Rumination is a syndrome of involuntary recurrent regurgitation.

Retching is the involuntary act of abdominal contraction against a closed glottis without expulsion of gastrointestinal content into the mouth, often preceding vomiting.

What disease states can produce this sign or symptom?

Acute nausea and vomiting

Common

Infectious gastroenteritis

Drugs

Gastric outlet obstruction

Intestinal obstruction

Head injury

Pregnancy

Intra-abdominal inflammation

– acute cholecystitis

– acute appendicitis

– peptic ulcer disease

– acute hepatitis

– acute pancreatitis

– Crohn's disease

– peritonitis

– mesenteritis

Motility disorders

– gastroparesis

– functional dyspepsia

Vestibular disturbances

Migraine headache

Less common

Endocrinopathies

– hyperthyroidism

– hypoparathyroidism

– hyperparathyroidism

– Addison's disease

– diabetes mellitus

Meningitis

Hydrocephalus

Intracranial lesions

Neurysm/hemorrhage

Tumor

Abscess

Severe pain

Chronic nausea and vomiting

Drugs

Pregnancy

Motility disorders

– gastroparesis

– functional dyspepsia

– chronic intestinal pseudo-obstruction

Functional nausea and vomiting

Cyclic vomiting syndrome

Intra-abdominal inflammation

Endocrinopathies

Medications/drugs associated with nausea and vomiting

Opiates

Cancer chemotherapeutics

– cisplatin

– etoposide

– cytarabine

– dacarbazine

– doxorubicin

– nitrogen mustard

– cyclophosphamide

– ifosfamide

– methotrexate

– vinblastine

– 5-fluorouracil

NSAIDs

Antibiotics

– erythromycin

– sulfa

– tetracyclines

Inhaled anesthetics

Theophylline

Digoxin

Dopamine agonists

Beta-blockers

Calcium-channel blockers

Lubiprostone

Antivirals

– acyclovir

Diuretics

Oral hypoglycemics

Anticonvulsants

Cannabinoids

What urgent or emergent measures should be initiated even before the diagnosis is established?

The first step in the evaluation of the patient with nausea and vomiting is emergently assessing and stabilizing the patient. This will include assessment of vital signs, particularly signs of orthostasis, abdominal examination for tenderness and rigidity, and sending out routine blood tests such as CBC, electrolytes, amylase and lipase, and measures of renal function and urinalysis.

For women of child bearing age, a serum HCG (human chorionic gonadotropin) should be sent. If clinically suspect, a serum and urine toxin screen should also be sent. Therapy should begin with intravenous fluids and antiemetics.

What is the appropriate initial diagnostic approach to identify the specific underlying disease?

After initial management and stabilization of the patient, attention should now be focused on evaluation for possible emergent and life-threatening etiologies of nausea and vomiting. These causes include acute infectious or toxin-mediated gastroenteritis, bowel obstruction, severe abdominal inflammatory processes such as pancreatitis, appendicitis or bowel infarction, or an acute intracranial cause such as bleeding.

Clinical clues in identifying causes of nausea and vomiting

Infectious causes

Patients with acute on set viral, bacterial, or bacterial toxin-mediated gastroenteritis commonly present with fever, chills associated with or shortly followed by acute onset nausea, vomiting, and retching. In contrast to obstruction, vomiting is commonly nonproductive and does not relieve symptoms of nausea. Diarrhea also commonly accompanies nausea and vomiting but usually has a later onset in the illness.

These patients tend to have a soft abdomen. The abdomen, however may or may not be distended, depending on whether there is accompanying intraluminal bowel secretion as a result of the toxin-mediated process. The bowel sounds are not typically high pitched, however.

A CT scan may be normal or demonstrate diffuse small bowel thickening for viral gastroenteritis or focal thickening, particularly of the ileum and/or colon in patients with a bacterial cause such as E. coli or Campylobacter jejuni. The white blood cell count is commonly elevated but not always.

Bowel obstruction

These patients characteristically describe symptoms of abdominal distention; productive emesis, which temporarily relieves the nausea; and colicky abdominal pain. The content of the emesis will depend on the level of obstruction, with bilious emesis associated with high obstruction and feculent emesis associated with low obstruction.

Gastric outlet obstruction may present with nonbilious emesis and without pain. It is typically the consequence of peptic ulcer disease. In intestinal obstruction, the pain may be steady but peaks in steady wave times, with the onset of high pressure intestinal contractions trying to overcome the point of obstruction. The pain comes at regular intervals, similar to labor pain, and prompts the patient to move and change positions because of an inability to get comfortable. In between the waves of pain and vomiting, there are quiescent periods marked by a paucity of bowel contraction and re-accumulation of fluid. They may not have had a bowel movement for a longer-than-usual period of time prior to the onset of pain and distention.

On examination, these patients commonly have abdominal distention, unless they have recently had copious emesis. There is diffuse tenderness but usually without rebound or rigidity unless there is impending bowel infarction. The bowel sounds are high pitched and come in waves in parallel and as a reflection of bowel contractions. The white blood cell count may or may not be elevated. A CT scan of the abdomen and pelvis is the first and best test for evaluating for the presence of bowel obstruction.

Intra-abdominal inflammatory process

These patients tend to note a steady abdominal pain in accordance to the persistent inflammatory process. As there is broad differential for this category of any abdominal or pelvic organ, location of the pain is typically organ specific.

Patients with appendicitis will commonly start with a vague epigastric or supraumbilical mild pain that increases in intensity and becomes more focal and localized to the right lower quadrant. On examination, they will have tenderness and rebound that shifts to McBurney's point.

Patients with severe pancreatitis will note a diffuse periumbilical or epigastric pain radiating to the back, causing them to lie still. On examination, they appear uncomfortable but not in extremis. They typically express a tachycardia, often seemingly out of proportion to their overall appearance. On examination, however, they have marked voluntary and involuntary guarding, sometimes with rebound. Their white blood cell count is typically elevated and associated with elevations of amylase and lipase. CT scan is the best test to confirm and stage the severity of this diagnosis. It may also give evidence of cholelithiasis or pancreatic malignancy, two of the more common causes of acute pancreatitis.

Crohn's disease may manifest with both severe steady and colicky pain. It is commonly associated with diarrhea but not necessarily. These patients will express abdominal tenderness, particularly in the right lower quadrant and hypogastrium but usually without rebound. Voluntary guarding is present and sometimes may be accompanied by involuntary guarding. As a result, differentiating an acute presentation of Crohn's disease from appendicitis may be quite difficult. Initial CT scan demonstrates thickening and inflammatory stranding around the ileum and/or colon. An abscess or phlegmon may also be present. Bowel infarction presents with severe diffuse abdominal pain and commonly hypotension. Patients cannot move because of the severity of the pain. They have marked rebound and involuntary guarding on abdominal examination with associated tachycardia. White blood cell count is commonly elevated. In these patients, elevation of serum lactate, acidosis, and a CT scan with bowel thickening and sometimes free intra-abdominal pain are important clues to the diagnosis. It is important to note that in the early stages of bowel infarction, only an ileus may be present on CT.

Intracranial causes

Intracranial causes of nausea and vomiting may or may not be accompanied by neurologic or head-specific symptoms. Patients may complain of a severe headache, particularly in the presence of an acute process such as intracranial bleeding or infarction. Focal neurologic deficits may be present or more generalized signs such as disorientation and change in mental status.

The initial examination should focus on assessing for marked elevation in blood pressure or fluctuating blood pressure as may be seen in brain stem herniation. In addition to a focus neurologic exam for extremity weakness and discoordination, an eye exam for papiledema should be performed. A CT scan of the head is the best initial test for diagnosis.

Intra-abdominal but nongastrointestinal causes

Many nongastrointestinal organ diseases may contribute to acute onset nausea and vomiting. In women, both complicated and uncomplicated pregnancy needs to be emergently evaluated. This is particulary true with ectopic pregnancy, which may present with nausea, vomiting, and hypogastric pain.

A serum HCG and pelvic ultrasound are most helpful in making these diagnoses. Ovarian torsion may also present with acute onset nausea, vomiting and abominal pain. These patients may describe both a steady and colicky right or left lower quadrant pain. Pelvic examination and ultrasound are most helpful in this situation.

Renal colic commonly causes nausea and vomiting. The emesis is usually nonproductive. These patients typically described a colicky pain, which may be localized to the flank, lower quadrant, pelvic, or, in the case of a male patient, the testicle; however, the abdomen may be the only site of pain. Initial urinalysis may demonstrate gross or microscopic blood. Unenhanced CT is the best test for establishing the diagnosis.

See Figure 1 and Figure 2 for algorithms for approaches to acute and chronic nausea and vomiting.

Algorithm for approach to acute nausea and vomiting

Algorithm for approach to chronic nausea and vomiting.

What is the diagnostic approach if this initial evaluation fails to identify the cause?

In most cases, once obstruction, other emergent intra-abdominal events, toxicity, or intracranial etiologies have been ruled out, the approach may shift to symptom management as other etiologies are considered and evaluated in appropriate fashion. Often, this procedure can be completed in the outpatient setting if symptoms are controlled to the point where the patient can tolerate oral intake.

In most patients, an upper endoscopy is appropriate to exclude mucosal causes in the esophagus, stomach, or duodenum. In most cases, a patient with unexplained acute nausea and vomiting that becomes chronic should be referred to a gastroenterologist.

Historical details are useful with chronic nausea and vomiting. Many cases are functional disorders, although functional diagnosis cannot be made with an acute presentation and no prior history of nausea and vomiting. A diagnosis of functional nausea and vomiting should only be made when vomiting is present weekly and CNS and metabolic causes have been ruled out. Cyclic vomiting syndrome is characterized by stereotypical bouts of recurrent nausea and vomiting, with variable asymptomatic periods in between not explained by a structural or metabolic condition.

Rumination should not be confused with the eating disorder bulimia, which is characterized by intentionally induced vomiting. Ruminators describe no retching and often reswallow the regurgitant.

Motility disorders are common causes of chronic nausea and vomiting. Gastric motility disorders are most common. Gastroparesis is defined by delayed gastric emptying on soild phase scintigraphy. Four-hour retention of greater than 10% to 15% of the radiolabelled meal indicates delayed gastric emptying. Gastroparesis may be a consequence of diabetes or following gastrointestinal surgery or infection but is often idiopathic. Rapid gastric emptying producing the so-called "dumping syndrome" can be associated with nausea, bloating, and vomiting but is usually restricted to patients with a history of gastrojejunostomy, partial gastric resection, vagotomy, or pyloroplasty.

Intestinal dysmotility is far less common than is gastric dysmotility. Chronic idiopathic intestinal pseudo-obstruction may present with nausea and vomiting much like gastric motility disorders, but pain and distension are usually accompanying features. Dilated small intestine on barium series without colonic dilation is diagnostic, but early disease may require gastroduodenal manometry to make a definitive diagnosis.

A number of neurologic conditions may cause chronic nausea and vomiting, including slow-growing tumors and other causes of increased intracranial pressure, migraine headaches, or vestibular disorders among the most common. An MRI will have increased sensitivity and referral to a neurologist may be necessary.

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